What does release of information include?

HIPAA does not specify any requirements for a patient's written request to access information, but a good form would typically include: (i) the patient's identifying and contact information; (ii) a specific description of the records requested (including the date range and type of records requested); (iii) the format

Philadelphia Pennsylvania Waiver, Release and Authorization to Use a Description of Patientýs Psychological History and Treatment in a Book without Identifying the Name of Patient

Name: Philadelphia Pennsylvania Waiver, Release and Authorization to Use a Description of Patientýs Psychological History and Treatment in a Book without Identifying the Name of Patient
Brand: US Legal Forms
Rating: 4.68 (233 reviews)

Category:

Releases and Waivers - Books

State:

Multi-State

County:

Philadelphia

Control #:

US-04321BG

Format:

Instant download

Description

A release gives up a right, such as releasing one from his/her liability for harm or damage that may occur from performing under a contract, or participating in an activity. A release acts as some assurance to the person requesting the release that he/she will not be subjected to litigation resulting from the person giving the release. The term waiver is sometimes used to refer a document that is signed before any damages actually occur. A release is sometimes used to refer a document that is executed after an injury has occurred.

This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.

How to fill out Philadelphia Pennsylvania Waiver, Release And Authorization To Use A Description Of Patientýs Psychological History And Treatment In A Book Without Identifying The Name Of Patient?

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FAQ

Write the name of your child's doctor and any other medical providers or facilities. Provide a phone number and location where you can be contacted. If possible, provide an alternate phone number as well. At the bottom of the release, provide your name, home address and date and sign the paper.

The core elements of a valid authorization include: A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.

An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the

An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

A signature and date that the authorization is signed by an individual or an individual's representative. If a representative is signing the form, the relationship with the patient must be detailed along with a description of the representative's authority to act on behalf of the patient.

HIPAA does not specify any requirements for a patient's written request to access information, but a good form would typically include: (i) the patient's identifying and contact information; (ii) a specific description of the records requested (including the date range and type of records requested); (iii) the format

If you want to release everything, then include this language: "I authorize the release of my complete health history (including all information related to HIV or AIDS, mental health care, communicable diseases, or treatment of alcohol and drug abuse)."

compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.

Valid HIPAA Authorizations: A Checklist No Compound Authorizations. The authorization may not be combined with any other document such as a consent for treatment.Core Elements.Required Statements.Marketing or Sale of PHI.Completed in Full.Written in Plain Language.Give the Patient a Copy.Retain the Authorization.

Philadelphia Pennsylvania Waiver, Release and Authorization to Use a Description of Patientýs Psychological History and Treatment in a Book without Identifying the Name of Patient

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